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v1G��u� ? , c {<gS�Zf <br />'• `'(' + J Form Approved. OMB No. 2050-0039 <br />ease <br />print or type. (Form designed for use o .,oftdmter.) - <br />HAZARDOUS 1. n'rator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />QQQ894528 FLE <br />MANIFEST IO) <br />s Namal1and Mailing Address !�c-\ Generators Sile Address(if dievent than mailing address) <br />_1 ►tCi '.ltA UIVi�I�I� ii �i�+�. <br />JCiQC+UI() l l X n� <br />;u��UX.rc Ar Icl�rforrf S!Phone: <br />r <br />�I S. Number <br />r 1 Company Name <br />P ter 2 Company NameU.S.EPAIDN b <br />� <br />U.S. EPA ID umber <br />nesignated Facility Name and Site Address 7 <br />L►Pc4r1 ��C�rbL"f.�tnu�"t�%�;'laa�l;lccl5�°�.w-YPS��'iu»{,x 1l�aclll��� F�=`�7� <br />Ll -I `qui II Nw I A -Is <br />0 <br />'r <br />Fadlity's Phone: "IN li-,io' <br />mp' '' 10. Containers it. Total 12. Unit <br />ga 9b. U.S. DOT Description (including Proper Shippm me, Hazard rsls' At5m r, 13. Waste Codes <br />Quantity rWt.Nol. <br />HM and�Packing Group (if any)) No. Type <br />fir% <br />I-ICU,ci n.c'�+ I <br />1�lAmmabl�.. , /(Tj�rnn>Yr <br />-1) CF�Nw),3,ttni�3,�tGlC) <br />-1-17 L; 1etam Ill 'As <br />/hr <br />I�E'461, n'1aiEr Ic11,Ehajr) 11AerUll Cbl <br />/\ Ia,G'�fYi 1�G 1 tl (F1 H LJ J 31 UIl l (r I�Ci I I "(( lr c F , w <br />1 <br />14. Special Handling Inshuctions and Additional Intonnation <br />I.�CH�1iC>Ce�I -�) J x�J�111 1�Ci��RfC.�`J <br />V Ll <br />C 11 J.aD4q <br />t\cmc ra i (� <br />15, GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelyclescdbed above by the propershippingname and are classified packaged, <br />in for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />marked and Iabeledrplacarded, and are in all respects proper condition <br />Exporter, I certify that the contents of this consignment conform to the terms of the allached EPA Acknowledgment of Consent. ` <br />I ceNfy, that the waste minim ed on statement identified in 40 CFR 262.27(a) (if I am a large quantity genera ar) or Ib) (it I am a small quantity generator) is true. <br />Day Year <br />ni rato eros Pane typed Name �a. igna ure on <br />1 lrtJ IL ee-I�-it <br />16.Intemadonai Shipments ❑Import to U.S. ❑Export from U.S. Port of entryleAt <br />Z <br />— <br />Transporter signature fore rts onl Date leaving U.S.: <br />LU <br />17. Transporter AcknoWedgment of Receipt of Matedals %' •� <br />gnalure, -" "" , Month Day Year <br />Trans r PnrdmllTyped Name <br />lob a&" d" <br />a <br />1 A "�-t Ifr C" r• A Doth Oay ear <br />ig e <br />Transporter 2 PrintedR ed Name ( <br />1 h <br />^ <br />16. Discrepancy - <br />❑ Type ❑ Residue ❑ Partial RejecdCn ❑ Full Rejection <br />18a. Discrepancy Indiction Space ❑ryry <br />Quantity <br />'%� y �, �,7{r/ `'4 `Ix)'f �'` •�", Manifest Reference Number: <br />181b. Alternate Facility(or Generator) - - .:. U.S. EPA ID Number <br />LL <br />ILL! <br />Facili 's Phone: Month Day Year <br />lea Signature ofAltemate Facility(or Generator) <br />Q <br />z <br />(D <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />20. Designated Facility Owner or Operator. Ceriifration of receipt of hazardous materials covered by the manifest except as noted in Item 18aVJ on Day Year <br />Nae gnalure <br />rj"ntedRyped <br />• <br />nemr_unrert eerII ITV TO rPNFRATOR <br />EPA Form 8400-22 (Rev. 3-05) Previous editions are obsolete. <br />